Transcript 16 - Ocular Emergencies

Ocular emergencies
Erin Moorcones, RN, MSN
The Eye
Anatomy and physiology
The eyes are protected by bony
structures, eyelids, and sclera. Lacrimal
glands secrete tears, which continuously
bathe eye to decrease friction and remove
minor irritants.
Light enters the eye through the cornea,
passes through the lens, and reflected off
the retina. Amount of light entering is
controlled by iris.
Patient Assessment
A potential threat to vision is triaged as
emergent, whereas patient with a
reddened eye with no potential for vision
loss could be non-urgent.
Visual Acuity
Visual acuity should be done on all
patients with eye or visual complaint,
unless patient sustained chemical
exposure to eye where irrigation is
priority.
Pupil Examination
Includes assessment of shape, size, and
reactivity.
Up to 20-25% of population have unequal
pupils ( physiologic anisocoria- pupils vary
<1mm with brisk reaction to light) as a
normal finding.
FYI* oval pupil may indicate tumor or retinal
detachment
* teardrop pupil suggest ruptured globe- teardrop
pointing to rupture site
Anterior segment
Composed of sclera, conjunctiva , cornea,
anterior chamber, iris, lens and ciliary
body.
Inspect clearness of cornea.
• Ocular movement• assess cranial nerves
General strategy
HPI
* Pain- PQRST
* Appearance of eye- swelling, redness,
aysmmetry
* changes in vision, tearing, itching, discharge
PMH*pre-existing disease- DM, htn, sicle cell
* ocular- lenses, surgery, glaucoma, eye disease
Pysch/ social* work environment, school, hobbies
Assessment
Consultation required
Age related considerations
Geriatric considerations
Vision gradually dimishes until age 70, then rapidly
Decreased accuracy of visiontesting
Eye accomodation decreases with age
Older adults complain of eye dryness.
Cataracts more common with advancing age. 1 in 3 adults
age 80 affected.
More liekly to experience glaucoma, detached retna, retinal
bleeding
PEARLS* health referrals
* Protected environment
Infections
Lid infectionsHordeolum- infection of eyelash oil
gland. Apply warm compress 4 times a
day with ophthalmic antibiotics
Chalazion
Internal hordeolum caused by chronic
inflammation.
Patient presents with several weeks of painless,
localized swelling. If it affects vision may have
I&D
Herpes Simplex of eye
Conjunctivitis
Inflammatory condition of membrane that lines
the eyelids and covers exposed surface of sclera.
Causes- bacteria, virus, chlamydia/gonorrhea,
chemical burns, foreign bodies,exposure to
irritants.
Assessment
HPI
-redness, abrupt onset, unilateral/bilateral, pain,
FB sensation, discharge, edema, itching, burning,
fever
PMH
-URI, contact with others, medications (steroidsmay exacerbate infections, esp w/Herpes
infections)
Objective data-distress, visual acuity, cornea, pupil,
conjunctiva, chemosis, discharge, eyelid edema
Assessment
Diagnosticculture, fluorescein stain, gram stain
Interventions
- cleanse eyelids (inner-outer)
- warm compress, bacterial/cool compress, viral
- medications
- education
Anterior Uveitis/Iritis
Uveitis-inflammation of one or all the parts of the
uveal tract (iris, ciliary body, choroid)
S/S- intense unilateral pain, conjunctivitis,
edema, lacrimation, photophobia.
Posterior uveitis (choroiditis)- rare, seen in CMV
infections associated with AIDS
TreatmentWarm compress, dark enviornment
Topical steroid,
Eye rest
f/u referral
Periorbital/Orbital Cellulitis
Key assessment pieces
S/S- Temperature, Decreased pupillary reflexes
Diagnostic- CT, culture, CBC, LP
Treatment- warm compress, excision of abscess,
antibiotics, F/u
Glaucoma
S/S- red eye, pain, HA, bluured vision,
photophobia, n/v.
Physical exam- decreased visual acuity, corneahazy, steamy, intraocular pressure 40-80,
hardness to globe with palpation,
Diagnostic- slit-lam, tonometry
Treatment- beta antagonists, pilocarpine droops
Acute angle-closure glaucoma
PACG increases with age and more common in
women and eskimo’s and those of Asian decent.
Estimated to be the cause of 46% of all cases of
irreversible blindness.
S/S- severe eye pain, fixed or slightly dilated
pupil, foggy appearing cornea, severe headache,
complaints of halo’s around lights, diminished
peripheral vision
Treatment- must decrease IOP quickly
Central retinal artery occlusion
Sudden, painless, unilateral loss of vision caused
by thrombus/emboli
Prompt recognition and intervention w/I 1-2 hrs
of onset necessary.
Treatment- referral
ocular hypotensive drops carbon gas for
vasodilation
Trauma
Blunt trauma- caused by MVC, fall, assault
Symptoms include- ecchymosis, redness
Resolution of bruising usually resolves in 2
weeks.
Orbital fractures
• Involve the orbital floor and orbital rim
• Orbital floor fracture, aka blowout fracture. Direct
trauma causes increase in IOP. Orbital contents
may herniate into the maxillary or ethmoid
sinuses.
• Diagnosis- by observation of periorbital
ecchymosis, subconjunctival hemorrhage,
periorbital edema, upward gaze and diplopia.
• CT or MRI
• Orbital fractures not emergency unless visual
injury or globe injury present
Hyphema
Bleeding into anterior chamber of eye. Occurs
when blood vessels of the iris rupture and leak
into the clear aqueous fluid of anterior chamber.
Symptoms- pain, photophobia, blurred vision
Treatment- beta blockers to dec IOP, mydriatic
agents, steroids, pain mgmt, anti emetics
Subconjunctival hemorrhage
Harmless eye condition that is usually triggered
by sneeze, cough, Valsalva.
Symptoms- painless, bright red flat patch
Usually reabsorbs in 2-3 weeks
Globe rupture
Foreign Body
Most common is dust particle
Organic FB have higher incidence of
infection.
Metallic FB leave rust ring unless
removed w/I 12 hours
Inert FB do not cause infection, but
higher risk for penetration
Superficial Trauma
Corneal abrasionFB such as contact scratches, abrades, or denudes
optical epithelium. Damage to cornea exposes
corneal nerves causing tearing, eyelid spasms, and
pain.
May need topical analgesic to get visual acuity.
Assess eyelids to ensure no FB. Diagnosis with
fluorescein.
Corneal laceration
Ophthamolgy consult required.
Present similar to corneal abrasion
Burns
Chemical Burns- from acids, alkalis.
copious irrigation needed.
• Thermal burns- usually affects
eyelids.
• Radiation burns- UV or infrared